Amanda R. Jackson, NP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

19521 Issued in TN

Practice address

111 W Stone Dr Ste 110
Kingsport, TN 37660-6027

Phone

(423) 224-3701

Fax

(423) 224-3709

NPI assigned

Dec 15, 2014

Last updated

Jun 6, 2018By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jan 1, 2026 through Jan 1, 2028

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Wellmont Medical Associates, Inc.

  dba Ballad Health Medical Associates

  • Internal Medicine Physician
  • Johnson City, TN
  • NPI 1154789030
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1418601600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1528243200000",
    "number": "1447658919",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 E STONE DR",
            "address_2": "SUITE 2",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376603384",
            "telephone_number": "423-224-1110",
            "fax_number": "423-224-1130"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 W STONE DR STE 110",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376606027",
            "telephone_number": "423-224-3701",
            "fax_number": "423-224-3709"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1101 E Stone Dr",
            "address_2": "Suite 2",
            "address_purpose": "LOCATION",
            "city": "Kingsport",
            "state": "TN",
            "postal_code": "376603384",
            "country_code": "US",
            "telephone_number": "423-224-1110",
            "fax_number": "423-224-1130",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "378 Marketplace Dr Ste 5",
            "address_purpose": "LOCATION",
            "city": "Johnson City",
            "state": "TN",
            "postal_code": "376042361",
            "country_code": "US",
            "telephone_number": "423-282-0751",
            "fax_number": "423-282-1577",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "AMANDA",
        "middle_name": "R.",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2014-12-15",
        "last_updated": "2018-06-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TN",
            "license": "19521",
            "primary": true
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "TN",
            "license": "182185",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q010785",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1447658919",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ingles Markets Inc (Ingles Pharmacy #072)
• Amanda Davis Ingram, MD
• Genesia Dickson Irick, FNP
• Michael Itidiare, D.O., M.B.S
• Itl Pharma
• Brian Jackson
• Elizabeth Michele Jackson, M.D.
• Kelly Nicole Jackson, FNP
• Zachary Lynn Jackson
• Rekha Jain, M.D.

• Family Nurse Practitioner in Kingsport, TN
• Providers in Kingsport, TN by specialty
• Family Nurse Practitioner in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.